Limited evidence behind decision to cut long phone consultations

The warnings were clear – cutting MBS item numbers for telephone consultations longer than 20 minutes would disproportionately affect the most vulnerable.
 
‘We risk leaving patients behind,’ then RACGP President Adjunct Professor Karen Price said when the place of longer phone consultations in telehealth appeared threatened in April 2021. 
 
Each time their removal was threatened, the college indicated that those with the most to gain from telehealth are also often disadvantaged by the reliability of their internet connection and understanding of technology – a significant drawback if video is the only means allowed for longer remote consultations.
 
Older and economically disadvantaged patients would suffer most if there were no longer extended phone consultation options, the RACGP reiterated when the rebates were given a temporary reprieve in July that year for COVID hotspots.
 
‘[The MBS items] need to be here forever,’ Dr Michael Bonning of the RACGP Expert Committee – Funding and Health System Reform (REC–FHSR) told newsGP when they were given yet another temporary stay of execution in January 2022.
 
Six months after that, however, and the Level C phone consult rebates were discontinued – except for patients needing advice on the prescription of COVID-19 antivirals and those in the most remote parts of the country.
 
At the time, Federal Health and Aged Care Minister Mark Butler stressed that MBS items remained in place for Level A, and Level B phone consults up to 20 minutes.
 
Now, health researchers at Deakin University have lent academic weight to the argument that the removal of Level C items is likely having the biggest impact on those who can least afford it.
 
In an article, ‘Long telephone consultations for GP appointments: evidence versus policy’ published in the latest Medical Journal of Australia, they included analysis of long telehealth consultation uptake across 140 regional primary care practices in Western Victoria.
 
‘There was high uptake of video consultations at the onset of COVID-19, but only in areas of higher socio-economic advantage and located closer to urban centres,’ they concluded.
 
‘These data indicate that there is a barrier to increasing the uptake of video-based items in socio- economically and geographically disadvantaged areas.
 
‘Overall, the removal of telephone consultations potentially disadvantages groups of patients who tend to have higher healthcare needs, such as those from rural and regional areas, those facing socio-economic disadvantage, older Australians, and some minority or priority groups.’
 
The authors say Australia ‘needs long telephone consultations’ until there are proven strategies to reduce the barriers to video consultations.
 
‘We need to recognise that there was evidence of substantial use of [the long phone consultation MBS] item and there is little evidence to support a change, including consideration of potential problems such as over-servicing and adverse health and experience outcomes in different contexts,’ they wrote.
 
Dr Colin Metz, who also sits on the REC–FHSR, believes patient care is being unnecessarily compromised.
 
‘The main issue is who is driving the push for video consultations,’ he told newsGP.
 
‘It’s not the patient. I can count on one hand the number of patients who request a video consultation since COVID started. 
 
‘Why is it that the department can have such a penchant for video consultations when the patients don’t really see the need for them? 
 
‘Who is the Medicare system set up for? The bureaucrats in Canberra or the patients?’
 
For Dr Edwin Kruys, another member of the REC–FHSR, the points in the MJA article accurately reflect his own view on the use of video.
 
‘My personal experience with video consultations is that there are often issues with regards to reception, bandwidth, access, user control and digital literacy, whereas telephone almost always works,’ he told newsGP.
 
Dr Metz raises a further practical query.
 
‘What happens if … a phone conversation went longer than usual?’ he said.
 
‘Are they advocating we tell the patient to stop talking because their funding has run out or do we tell them to put down the phone and start a video consultation? Or do they suggest we just give a longer consultation at the same price?’
 
Dr Kruys also agrees that those who need quality care most are likely to be the worst affected by the lack of access to the Level C phone rebate.
 
‘Vulnerable patients often need more time,’ he said.
 
‘There is a pressing need to future-proof our healthcare system. Facilitating non-face-to-face care is an essential element, and this includes long phone consultations.’
 
As well as making sense from an infection control perspective, allowing access to the broadest range of options of telehealth options will benefit the widest variety of patients, according to Dr Kruys. 
 
‘Providing a suite of MBS item numbers for short and long telephone and video consultations will benefit primary care delivery, especially rural and regional patients, mental health patients, patients living with chronic and complex health conditions and other vulnerable groups,’ he said.
 
‘I would urge decision makers in the Government and the Department of Health to please listen to patients and health providers.
 
‘Don’t force people into using video consultations and don’t use the argument as an excuse to save health dollars.’
 
Dr Metz says another issue is complexity. 
 
‘You can do a mental health care plan review via telephone, but not a new plan,’ he said. 
 
‘You can do a mental health care plan review over the phone, but not any of the chronic disease management plans over the phone.
 
‘Telephone consultations for blood-borne viruses, sexual or reproductive health by a GP can be done either via phone or via video.
 
‘Patients and doctors get confused by all these changes and different rules when there is no scientific basis for video consults being better than phone consults.’
 
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